The Promise and Challenges of Universal HIV Screening

By Jeffrey Laurence, M.D.

August 16, 2010—Antiretroviral therapy (ART) for HIV not only extends and improves the lives of HIV-positive individuals but can lower the number of new infections in a population. Mathematical modeling studies, including some supported by amfAR, have shown that early treatment can reduce the likelihood of transmission by lowering the level of virus in blood and genital secretions. However, ensuring that infected individuals begin treatment early—thus maintaining optimal health for patients and making them less infectious to others—means that these individuals must be aware of their HIV status.

Dr. Roland Merchant

Unfortunately, in the U.S., as in most other countries, HIV-positive individuals are not usually identified until late in the course of their infection. Writing in the July 21 issue of the prestigious Journal of the American Medical Association, amfAR-supported researcher Dr. Roland Merchant of Brown University discusses this problem in his review of two studies that explore the promise of and impediments to universal HIV screening in healthcare settings, which could provide an opportunity to diagnose infection earlier.

Merchant and his co-author, Dr. Michael Waxman, note that in 2006 the U.S. Centers for Disease Control and Prevention (CDC) advised healthcare providers to test all 13- to 64-year-old patients for HIV. According to the recommendations, testing should occur regardless of a person’s medical condition or his or her actual or perceived risks for infection. The CDC recommended an “opt-out” approach by which patients are informed that they will be tested unless they decline. Including the HIV antibody test with other routine medical tests, according to the CDC, would also help remove the stigma often associated with HIV testing.

In their commentary on the two studies, which focused on HIV testing rates in cancer clinics and in an emergency room, respectively, Merchant and Waxman point out that the CDC recommendations are not being implemented in these two healthcare settings.

A study of cancer centers at nine prominent medical centers in the U.S. found that patients were typically not screened for HIV. Yet HIV infection is a risk factor for several kinds of cancer, not only those traditionally associated with an AIDS diagnosis, such as Kaposi’s sarcoma, cervical cancer, and lymphoma. In addition, HIV-positive cancer patients can benefit greatly from ART.

In a CDC study conducted at the emergency room of an urban hospital, HIV screening was offered to all patients, but more than 75 percent declined to be tested. Merchant and Waxman argue that the manner in which testing was presented to these patients—a clerk rather than a medical professional initiated the testing request—may be have been a crucial element in compliance. They conclude that “optimal models for HIV screening … most likely will not be a one-size-fits-all approach.” The challenge for future researchers is to identify those methods that are most efficient, effective, and self-sustaining. Dr. Merchant discussed some of these issues last year in an amfAR-funded think-tank on optimizing HIV treatment.